Improving caregiver preparedness in the care transition of stroke patients: a scoping review

Stroke is a life-threatening condition caused by the rupture of a brain blood vessel, potentially causing brain damage within minutes, severe disability, and even death. After initial hospitalization and rehabilitation, most stroke survivors return home, relying on their family members as caregivers for activities of daily living and treatments. This scoping review aimed to evaluate caregivers' readiness for transitioning stroke patient care to a home environment. We conducted a comprehensive search on Scopus, PubMed, ScienceDirect, and Google Scholar databases, followed by a secondary search to identify articles based on predefined criteria. A total of 14 articles were synthesized, leading to a series of findings: (1) there is a need to assess and identify caregiver needs, (2) the process needs relevant information, (3) caregivers are involved in the care process until the patients are discharged from the hospital, and (4) there is a need to offer support to caregivers. These results indicate that implementing strategies to enhance caregiver preparedness is crucial for the effective home-based care of stroke survivors.


INTRODUCTION
According to the World Health Organization (WHO), stroke is ranked as the second leading cause of death worldwide after cardiovascular disease.Stroke happens when a blood vessel in the brain bursts, leading to brain damage within minutes, severe disability, and even death.In the United States, stroke is a prevalent cause of mortality, with the American Heart Association (AHA) reporting about 795,000 cases annually in individuals over 45 as of 2018 [1][2][3].In Southeast Asia, the prevalence of stroke reached 11 million people each year.Indonesia, in particular, recorded a stroke prevalence of 10.9% in 2018 [4].
Following stroke, patients often experience prolonged impact [4].Motor and sensory impairment, verbal, cognitive, and emotional changes, as well as bladder dysfunctions, are common af-ter-effects of stroke and can significantly affect the quality of life, both in acute care settings and during at-home treatment [5,6].Therefore, stroke patients require ongoing comprehensive hospitalization, rehabilitation, and care from health providers and caregivers to deal with their daily living difficulties in mobility, self-care, and managing communication, but also their cognitive impairment, depression, and personality changes.
Caregivers are family members or hired professionals responsible for regularly looking after sick patients and meeting their needs [7].According to the Emblem Health & National Alliance for Caregiving (2010), there are formal caregivers (professional workers) and informal caregivers (volunteers) [8,9].In Indonesia, caregiving is predominantly undertaken by family members, reflecting the cultural emphasis on extended family support [10].However, this responsibility often leads to caregiver stress, anxi-ety, financial strain, and health and social welfare issues, especially when their needs are overlooked during the patient's recovery process [11][12][13].More than 40% of caregiver families experience emotional stress and excessive burden [14].Therefore, it is necessary to prepare the families to better navigate the recovery process, as well as the financial and social fallout of a stroke.Assessing the caregivers' preparedness before the patient returns home is important to avoid psychological distress [15,16].The improvement in caregiver preparedness starts from the patient's nursing care and rehabilitation and continues upon the return to a home environment (care transition back into the community).
Numerous studies have highlighted a significant gap in the readiness of family caregivers to effectively manage and maintain the optimal health of stroke patients.Research findings indicate that caregivers frequently report a lack of preparedness for post-discharge care responsibilities, primarily attributed to insufficient knowledge and skills [17].This issue is further compounded by the fact that caregivers often need to seek out infor-  ing a comprehensive summary and conclusion on strategies to enhance caregivers' preparedness for transitioning from inpatient rehabilitation to home care.This gap justifies the need for research that consolidates and summarizes findings on this topic.This review aimed to identify and outline practical strategies that can improve the readiness of stroke caregivers for this critical transition.

Data sources and search strategies
This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines [22].The review focused on identifying articles relevant to im-mation and assistance independently without adequate guidance or support [18].
Previous research underscores the importance of evaluating caregiver preparedness and implementing appropriate strategies to enhance readiness [19].Systematic reviews and meta-analyses revealed that health coaching strategies for caregivers are essential during the transition process to improve the health of stroke survivors [20].Some authors evaluated the challenges and opportunities of caregivers after returning home [21].Qualitative research pinpoints the importance of systematic communication during care in supporting the transition and improving knowledge and skills for caregivers [21].The literature also delved into the preparedness and coaching strategies for caregivers, as well as challenges faced upon return to a home environment.Despite the existing research on the challenges faced by family caregivers of stroke patients, there is a notable gap in the literature regard- proving stroke caregivers' preparedness to transition from inpatient care to home-based rehabilitation.The time frame for the literature search was between 2010 and 2020.Articles were identified using several databases, namely Scopus, PubMed, Science-Direct, and Google Scholar.A secondary search was conducted on the references list from the previously obtained articles.The Medical Subject Heading (MeSH) used in the search followed the PCC framework (population, concept, context) (Table 1).

Identifying relevant sources
In this literature review, the initial screening process involved evaluating titles and abstracts of articles in Indonesian and English, focusing on the preparedness of stroke caregivers and strategies for improvement during the transition from inpatient rehabilitation to home care.The selection of articles was further refined based on the year of publication and the nature of the

Data extraction
After selecting articles that matched the research topic, data were selected for relevance, discussed, analyzed descriptively, and presented in the synthesis table.
After searching the four databases, 15,837 articles were identified and filtered based on the research population and the research objectives (from the abstract and article title).After the screening phase, 63 articles matched the research topic.The

RESULTS
Fourteen articles consistent with the research topic were selected.The studies were conducted in several countries, such as the United States, the United Kingdom, Canada, Brazil, Australia, and China.The methodologies used in these studies varied, encompassing quantitative, qualitative, and mixed methods approaches.Specifically, ten of these articles used qualitative methods with a grounded theory approach, three employed quantita-tive research techniques, and one was based on a mixed-methods study.
The articles selected for this study included various caregiver respondents (Table 3).One article focused on professional caregivers and their experiences transitioning from inpatient care to home settings.However, most caregivers in the studies were family members (e.g., wife, husband, and children).
The literature review identified four key findings, emphasizing crucial aspects of caregiver support in stroke patient care.These include (a) the need to assess and identify caregiver preparedness, Caregivers need information and rehabilitation services.

Ghazzawi et al. [36]
Descriptive Qualitative research To examine family caregivers' perceptions and experiences navigating the stroke rehabilitation system.
Fourteen participants with an average age of 63 years.
Interviews of 30-45 minutes were conducted in person or by telephone using a semistructured interview guide.
The health system should provide information and access to support in the community to meet the needs of stroke patients and caregivers.
Caregivers need information and support during the transition home.

Assessment and identification of caregiver preparedness
The caregivers' preparedness must be assessed and identified early before patients return home.In this case, several factors influence caregiver readiness: commitment, capacity, and knowledge in providing care to patients' families.In addition, to motivate and spiritually support the family members, a caregiver must have a commitment and capacity to carry out their role well [38].The commitment includes maintaining the relationship with the patient, motivation in caregiving, and spiritual support, while their capacity as a caregiver refers to considering their health status, ability to maintain a role, financial resources, and knowledge [24].In addition, environmental readiness is also one of the most common requirements for caregivers.Access is one component that aids caregivers in helping stroke patients recover [39].This assessment was carried out to identify the caregivers' needs and care plans that can improve the quality of the process and health as well as reduce expenses [17].A previous study [23] highlighted the importance of initial assessments before patients return home.Such an assessment helps families to be better prepared for the caregiving role and to adapt to post-rehabilitation activities more effectively.These findings align with other research emphasizing the need to identify specific skills, commitment, capacity, and knowledge essential for caregivers in managing the care of family members [40,41].This perspective is further reinforced by Langa et al., who argue that caregivers should have the commitment, capacity, skills, and knowledge to improve the quality of life before the patient's return home [42].The results of this assessment can direct health providers to deliver clear and relevant information according to patient needs.
(b) the necessity of providing caregivers with relevant information, (c) the importance of caregiver involvement up until the patient's preparation for discharge, and (d) the overall support required by caregivers [23-27, 29-35, 37] (Table 4).Furthermore, Creasy et al. [31] also explained that caregivers need financial support from family members or other relatives.In addition, caregivers also need significant support in managing emotions [30].

DISCUSSION
This review was conducted to summarize and describe concepts related to factors that need attention in the transition of care for stroke patients.The research identified several key aspects in this regard.needed to prepare families to care for patients during post-stroke rehabilitation.Several strategies can be carried out by a health provider to improve caregiver preparedness before patients return home, including (a) identifying and assessing caregivers' readiness to take on their roles, commitment, and capacity in their new position, (b) providing relevant information according to caregivers' needs such as disease prevention processes, actions, post-stroke complications, treatment, stress management, and rehabilitation, (c) involving caregivers in the care and discharge planning of stroke patients to provide experience and knowledge of the activities to be carried out during the rehabilitation process, and (d) providing support to caregivers from health providers, friends, and relatives to decrease the negative effect and increase enthusiasm in providing care.Therefore, healthcare workers should prioritize the preparation of caregivers before stroke patients are discharged home.This comprehensive approach involves assessing and identifying their needs, providing relevant information, getting involved in care and discharge planning, and supporting stroke patients at home.

Relevant information needs
Caregivers need to be informed about stroke from inpatient care until preparation for discharge.This information should be adapted to their needs [43].According to Yedidia et al. [44], patients and caregivers need information on available services, stress management, illness, and treatment.This is in line with research conducted by Alvarez et al. [45], who stated that a caregiver needs personalized information on treatment, nutrition, stress management, and ambulation to improve the quality of life for sick patients.Furthermore, Tsai et al. [46].supported this statement by stating that providing relevant information and counseling caregivers can help them meet the needs of patients' families.This information is provided from when the patient enters the hospital until the preparation to go home and is adjusted to the caregiver's needs [47].Moreover, nurses have a vital role in providing information and knowledge during the transition period [48].

Caregivers' involvement during in-patient care
Long-term care for stroke patients with limited resources requires active caregiver involvement until patients return home.Caregivers need to know their duties and responsibilities (e.g., helping with meals, participating in rehabilitation activities, and actively participating in decision-making during the acute care phase) [49].The involvement of caregivers in the hospital care process can help them learn to manage problems, increase knowledge, and reduce physical and emotional stress.This, in turn, has a positive impact on the health of stroke patients [50,51].This concept is supported by previous research, indicating that caregiver involvement in care and decision-making processes can enhance their overall experience, aiding them in being more prepared and improving the health of post-rehabilitation stroke patients [52].Consequently, this active participation of caregivers can lead to more tailored and effective clinical interventions and rehabilitation plans.

Support for caregivers
Increasing caregivers' desire to care for stroke patients is also required to support the care during rehabilitation.The support given to caregivers from various parties can reduce the burden and increase their enthusiasm [53].A study by Hekmatpou et al. underscores the importance of supporting caregivers in adapting to the changes that come with caring for a stroke patient.The research highlights that caregivers require emotional support, assistance from the patient's family, educational resources, and financial assistance to enhance the quality of life for both the caregiver and the patient [54].This is in accordance with research conducted by Cameron et al., which showed that a caregiver needs knowledge, training, and psychosocial support to care for patients.This statement is further reinforced by Cemy et al. [55].who suggest that caregivers need psychological, social, and spiritual support to care for their patients.

CONCLUSION
This scoping review uncovered critical aspects of improving caregiver preparedness in the care transition for stroke patients.The findings reveal that close relatives are the most suited for enacting the caregiver role for stroke patients.However, a plan is

13 .Figure 1 .
Figure 1.Search algorithm research (original or non-original research).Duplicates were excluded, and the results were presented.The inclusion criteria for the literature review were articles (a) focusing on the population of family caregivers of stroke patients, (b) addressing the concept of improving transition preparedness, (c) research set in the context of hospitalization or acute care, and (d) articles published internationally.

Table 2 . Continued. Grid synthesis for improving caregiver preparedness in the care transition of stroke patients
JOURNAL of MEDICINE and LIFE.VOL: 16 ISSUE: 12 DECEMBER 2023 Licensed under CC BY 4.0